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Vestibular Migraine Diagnostic criteria: A. At least five episodes fulfilling criteria C and D B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura 1 C. Vestibular symptoms 2 of moderate or severe intensity, 3 lasting between 5 minutes and 72 hours 4 D. At least 50% of episodes are associated with at least one of the following three migrainous features 5 : 1. headache with at least two of the following four characteristics: a) unilateral location b) pulsating quality c) moderate or severe intensity _ International Headache Society d) aggravation by routine physical activity 2. photophobia and phonophobia 6 3. visual aura 7 E. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder 8.

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Note 2 Vestibular symptoms, as defined by the Ba´ ra´ny Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of A1.6.5 Vestibular migraine, include: a) spontaneous vertigo: (i) internal vertigo (a false sensation of selfmotion); (ii) external vertigo (a false sensation that the visual surround is spinning or flowing); b) positional vertigo, occurring after a change of head position; c) visually induced vertigo, triggered by a complex or large moving visual stimulus; d) head motion-induced vertigo, occurring during head motion; e) head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).

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Notes 3,4,5 3. Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued. 4. Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours. 5. One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.

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6. Phonophobia is defined as sound-induced discomfort. It is a transient and bilateral phenomenon that must be differentiated from recruitment, which is often unilateral and persistent. Recruitment leads to an enhanced perception and often distortion of loud sounds in an ear with decreased hearing. 7. Visual auras are characterized by bright scintillating lights or zigzag lines, often with a scotoma that interferes with reading. Visual auras typically expand over 5–20 minutes and last for less than 60 minutes. They are often, but not always restricted to one hemifield. Other types of migraine aura, for example somatosensory or dysphasic aura, are not included as diagnostic criteria because their phenomenology is less specific and most patients also have visual auras.

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Vestibular Migraine v Migraine with brainstem aura Both migraine aura and migraine with brainstem aura (formerly: basilar-type migraine) are terms defined by ICHD-3 beta. Only a minority of patients with A1.6.5 Vestibular migraine experience their vertigo in the time frame of 5–60 minutes as defined for an aura symptom. Even fewer have their vertigo immediately before headache starts, as required for Typical aura with headache. Therefore, episodes of A1.6.5 Vestibular migraine cannot be regarded as migraine auras. Although vertigo is reported by more than 60% of patients with Migraine with brainstem aura, ICHD- 3 beta requires at least two brainstem symptoms in addition to visual, sensory or dysphasic aura symptoms for this diagnosis. Fewer than 10% of patients with A1.6.5 Vestibular migraine fulfil these criteria. Therefore, A1.6.5 Vestibular migraine and Migraine with brainstem aura are not synonymous, although individual patients may meet the diagnostic criteria for both disorders.

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V Menieres Migraine is more common in patients with Menie`re’s disease than in healthy controls. Many patients with features of both Menie`re’s disease and A1.6.5 Vestibular migraine have been reported. In fact, migraine and Menie`re’s disease can be inherited as a symptom cluster. Fluctuating hearing loss, tinnitus and aural pressure may occur in A1.6.5 Vestibular migraine, but hearing loss does not progress to profound levels. Similarly, migraine headaches, photophobia and even migraine auras are common duringMenie`re attacks

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In the first year after onset of symptoms, differentiation between them may be challenging, as Menie`re’s disease can be monosymptomatic with only vestibular symptoms in the early stages of the disease. When the criteria for Menie`re’s disease are met, particularly hearing loss as documented by audiometry, Menie`re’s disease should be diagnosed, evenwhenmigraine symptoms occur during the vestibular attacks. Only patients who have two different types of attacks, one fulfilling the criteria for A1.6.5 Vestibular migraine and the other for Menie`re’s disease, should be diagnosed with both disorders. A future revision of ICHD may include a vestibular migraine/Menie`re’s disease overlap syndrome

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Menieres Ten-point scale for the clinical diagnosis of MD [7] [7] Based on clinical history. One point awarded to each of the following. The closer the score is to 10, the more likely the patient is to have MD. Rotational vertigo Attacks of vertigo lasting >10 minutes Rotational vertigo associated with 1 or more of hearing loss, tinnitus, or aural pressure Sensorineural hearing loss Fluctuating hearing loss Hearing loss or fluctuation associated with vertigo, tinnitus, or aural pressure Peripheral tinnitus lasting >5 minutes Tinnitus fluctuating or changing with 1 or more of the following: vertigo, hearing loss, or aural pressure Aural pressure/fullness lasting >5 minutes Aural pressure fluctuating or changing with vertigo, hearing loss, or tinnitus.

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Migraine with brainstem aura Description: Migraine with aura symptoms clearly originating from the brainstem, but no motor weakness. Diagnostic criteria: A. At least two attacks fulfilling criteria B-D B. Aura consisting of visual, sensory and/or speech/ language symptoms, each fully reversible, but no motor1 or retinal symptoms C. At least two of the following brainstem symptoms: 1. dysarthria 2. vertigo 3. tinnitus 4. hypacusis 5. diplopia 6. ataxia 7. decreased level of consciousness D. At least two of the following four characteristics: 1. at least one aura symptom spreads gradually over _5 minutes, and/or two or more symptoms occur in succession 2. each individual aura symptom lasts 5-60 minutes2 3. at least one aura symptom is unilateral3 4. the aura is accompanied, or followed within 60 minutes, by headache E. Not better accounted for by another ICHD-3 diagnosis, and transient ischaemic attack has been excluded.

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Notes: 1. When motor symptoms are present, code as Hemiplegic migraine. 2. When for example three symptoms occur during an aura, the acceptable maximal duration is 3_60 minutes. 3. Aphasia is always regarded as a unilateral symptom; dysarthria may or may not be. Comments: Originally the terms basilar artery migraine or basilar migraine were used but, as involvement of the basilar artery is unlikely, the term migraine with brainstem aura is preferred. There are typical aura symptoms in addition to the brainstem symptoms during most attacks. Many patients who have attacks with brainstem aura also report other attacks with typical aura and should be coded for both Migraine with typical aura and Migraine with brainstem aura. Many of the symptoms listed under criterion C may occur with anxiety and hyperventilation, and therefore are subject to misinterpretation.